Basic Information
Provider Information
NPI: 1447490446
EntityType: 2
ReplacementNPI:  
OrganizationName: DSW ANESTHESIA SERVICES LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 11405
Address2:  
City: FORT SMITH
State: AR
PostalCode: 729171405
CountryCode: US
TelephoneNumber: 4797852555
FaxNumber: 4797853555
Practice Location
Address1: 3002 ROGERS AVE
Address2:  
City: FORT SMITH
State: AR
PostalCode: 729014232
CountryCode: US
TelephoneNumber: 4797852555
FaxNumber: 4797853555
Other Information
ProviderEnumerationDate: 03/03/2009
LastUpdateDate: 03/03/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: WILLIS
AuthorizedOfficialFirstName: DONOVAN
AuthorizedOfficialMiddleName: S
AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 4794622859
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: CRNA
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
174400000XC01497ARY193400000X SINGLE SPECIALTY GROUPOther Service ProvidersSpecialist 

No ID Information.


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